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<title>Cash2u.ca: Payday loan online application for Canadians</title>
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<br/><br/><br/><h1><a style="color:white;" href="apply.php">Cash to you</a></h1><p id="headpara"><a style="color:white;" href="apply.php">Simple Easy Fast - Your payday loan</a></p>
</div>
</div>

<table cellspacing="4" cellpadding="1" border="0" style="margin:5px;height:50px;width:740px;background-color:#084c8d;border:1px solid #e5e5e5;color:white;font-size:110%;font-weight:bold;">
<tr><td width="20"></td>
<td width="90" align="center"><a class="headlink" href="NewAppliation.php">Application</a></td>
<td width="90" align="center"><a class="headlink" href="Employees.php">Employee</a></td>
<td width="130" align="center"></td>
<td width="110" align="center"></td>
<td width="90" align="center"></td>
<td width="90" align="center"></td>
<td width="140"></td>
</tr>
</table>

<div id="content">
    	<div id="Apphead" class="Apphead" style="margin: 20px 0 0 5px;">
        	<h3>LOAN APPLICATION</h3>
		<p>Returning customers, please <a style="color:green;" href="member.php">apply here</a> for a faster application<br/>
		   Please fill all the fields for this online application unless indicated 			as optional </p>
            
    	</div>
        <!-- EOD of Application Head -->    
          
        <div id="TopSectionWrapper" class="PersonalInfo">
		<div id="NewCust" class="NewCust">New Customer <?php echo "00".$NewCustomers;?></div>

	<!--Starting of Personal Information Section-->
	<div id="TitleInfo" class="TitleInfo"><h2>Your Personal Information - Step 1</h2></div>
	<form name="Profiles" method="post" action="applysecondpart.php" id="Profiles">
	<table cellspacing="4" cellpadding="1" border="0" style="margin: 0 0 0 0;">
		<tr>
                <td width="140" align="right">First Name:</td>
                <td width="170"><input type="text" style="width: 150px;" value="" name="fName"></td>
                <td width="230" align="right">Last Name:</td>
                <td width="160"><input type="text" style="width: 150px;" name="lName" value=""></td>
		</tr>
		

		<tr>
                <td width="140" align="right">Gender:</td>
                <td width="170">
			<select style="width: 130px;" name="gender">
				<option value="">- Select -</option>
				<option value="female" >female</option>
				<option value="male" >male</option>
			</select>
                <td width="230" align="right">Social Insurance Number:<br/><span style="color:green;font-size:small;">(SIN: 999-999-999)</span></td>
                <td width="160"><input type="text" style="width: 150px;" id="ssn" name="SIN" value=""></td>
		</tr>
				
		<tr>
                <td width="140" align="right">Date of Birth:<br/><span style="color:green;font-size:small;">(date: mm/dd/yyyy)</span></td>
                <td width="170"><input type="text" id="datebirth" style="width: 150px;" name="birthdate"/></td>
                <td width="230" align="right">Address:</td>
                <td width="160"><input type="text" style="width: 150px;" name="address" value=""></td>
		</tr>

		<tr>
                <td width="140" align="right">City:</td>
                <td width="170"><input type="text" style="width: 150px;" name="city"/></td>
                <td width="230" align="right">Province:</td>
                <td width="160">
		<select style="width: 150px;" name="mprovince">
		<option value="" <?php if($_POST["province"] == "") {echo "selected='selected'";}; ?>>Please Select your province</option>
                <option value="Alberta" <?php if($_POST["province"] == "Alberta") {echo "selected='selected'";}; ?>>Alberta</option>
                <option value="British Columbia" <?php if($_POST["province"] == "British Columbia") {echo "selected='selected'";}; ?>>British Columbia</option>
                <option value="Manitoba" <?php if($_POST["province"] == "Manitoba") {echo "selected='selected'";}; ?>>Manitoba</option>
                <option value="New Brunswick" <?php if($_POST["province"] == "New Brunswick") {echo "selected='selected'";}; ?>>New Brunswick</option>
                <option value="Newfoundland" <?php if($_POST["province"] == "Newfoundland") {echo "selected='selected'";}; ?>>Newfoundland</option>
                <option value="Northwest Territories" <?php if($_POST["province"] == "Northwest Territories") {echo "selected='selected'";}; ?>>Northwest Territories</option>
                <option value="Nova Scotia" <?php if($_POST["province"] == "Nova Scotia") {echo "selected='selected'";}; ?>>Nova Scotia</option>
                <option value="Nunavut" <?php if($_POST["province"] == "Nunavut") {echo "selected='selected'";}; ?>>Nunavut</option>
                <option value="Ontario" <?php if($_POST["province"] == "Ontario") {echo "selected='selected'";}; ?>>Ontario</option>
                <option value="Prince Edward Island" <?php if($_POST["province"] == "Prince Edward Island") {echo "selected='selected'";}; ?>>Prince Edward Island</option>
                <option value="Saskatchewan" <?php if($_POST["province"] == "Saskatchewan") {echo "selected='selected'";}; ?>>Saskatchewan</option>
                <option value="Yukon" <?php if($_POST["province"] == "Yukon") {echo "selected='selected'";}; ?>>Yukon</option>
                </select></td>
		</tr>


		<tr>
                <td width="140" align="right">Post Code:<br/><span style="color:green;font-size:small;">(Post Code:A9A-9A9)</span></td>
                <td width="170"><input type="text" id="post" name="postcode" style="width: 150px;"/></td>
                <td width="230" align="right">When did you move in:<br/><span style="color:green;font-size:small;">(Date: mm/dd/yyyy)</span></td>
                <td width="160"><input type="text" id="datein" style="width: 150px;" name="datein" value=""></td>
		</tr>

		<tr>
                <td width="140" align="right">Primary Phone:<br/><span style="color:green;font-size:small;">(Tel: (999) 999-9999)</span></td>
                <td width="170"><input type="text" id="phonep"  name="primaryphone" style="width: 150px;"/></td>
                <td width="230" align="right">Work Phone:<br/><span style="color:green;font-size:small;">(Tel: (999) 999-9999x99999)</span></td>
                <td width="160"><input type="text" id="phonew"  name="workphone" style="width: 150px;" value=""></td>
		</tr>

		<tr>
                <td width="140" align="right">Cell Phone <span style="color:green;font-size:small;">(optional):<br/>(Tel: (999) 999-9999)</span></td>
                <td width="170"><input type="text" id="phonec"  name="cellphone" style="width: 150px;"/></td>
                <td width="230" align="right">Driver License/Health Card #:</td>
                <td width="160"><input type="text" name="driver" style="width: 150px;" value=""></td>
		</tr>

		<tr>
                <td width="140" align="right">Email Address:<br/><span style="color:green;font-size:small;">(LoginID)</span></td>
                <td width="170"><input type="text" name="email" style="width: 150px;"/></td>
                <td width="230" align="right">Confirm Email Address:</td>
                <td width="160"><input type="text" name="cemail" style="width: 150px;" value=""></td>
		</tr>
		
		<tr>
                <td width="140" align="right">Password:</td>
                <td width="170"><input type="password" name="pwd" style="width: 150px;"/></td>
                <td width="230" align="right">Confirm Password:</td>
                <td width="160"><input type="password" name="cpwd" style="width: 150px;" value=""></td>
		</tr>

		<tr>
                <td width="140" align="right">Reference #1 Name:</td>
                <td width="170"><input type="text" name="r1name" style="width: 150px;"/></td>
                <td width="230" align="right">Reference #2 Name:<br/><span style="color:green;font-size:small;">(optional)</span></td>
                <td width="160"><input type="text" name="r2name" style="width: 150px;" value=""></td>
		</tr>
		
		<tr>
                <td width="140" align="right">Reference #1 Phone:<br/><span style="color:green;font-size:small;">(required)</span></td>
                <td width="170"><input type="text" id="phoner1"  name="r1phone" style="width: 150px;"/><br/><span style="color:green;font-size:small;">(Tel: (999) 999-9999 x 99999)</span></td>
                <td width="230" align="right">Reference #2 Phone (optional):<br/><span style="color:green;font-size:small;">(Tel: (999) 999-9999x99999)</span></td>
                <td width="160"><input type="text" id="phoner2"  name="r2phone" style="width: 150px;" value=""></td>
		</tr>


		<tr>
                <td width="140" align="right">Relationship :<br/><span style="color:green;font-size:small;">(with Reference  #1)</span></td>
                <td width="170"><input type="text" name="r1relation" style="width: 150px;"/></td>
                <td width="230" align="right">Where did you know:<br/><span style="color:green;font-size:small;">(www.cash2u.ca)</span></td>
                <td width="160">
		<select style="width: 150px;" name="advertisement">
			<option value="">- Select -</option>
			<option value="www.Cash2u.ca" >www.Cash2u.ca</option>
			<option value="Google" >Google</option>
		        <option value="Yahoo" >Yahoo</option>
		        <option value="Email" >E-Mail</option>
		        <option value="Internet" >Internet Search</option>
		        <option value="Friend" >Friend</option>
			<option value="Other Websites" >Other Websites</option>
		        <option value="Other Media" >Other Media</option>
		</select></td>
		</tr>
	</table>	
	
<!--for submit button-->
	<table>	
	<tr><td width="700" align="center"><input type="submit" value=" &nbsp;Next &gt;&gt; "/></td>
		</tr>

</table>
	</form>
	<script type="text/javascript">
var frmvalidator  = new Validator("Profiles");  
frmvalidator.addValidation("fName","req","Please enter your First Name");
frmvalidator.addValidation("lName","req","Please enter your Last Name");
frmvalidator.addValidation("gender","req","Please tell us your gender");
frmvalidator.addValidation("SIN","req","Please enter your social insurance number");
frmvalidator.addValidation("birthdate","req","Please tell us your birthday");
frmvalidator.addValidation("address","req","Please enter your address");
frmvalidator.addValidation("city","req","Please enter your living city");
frmvalidator.addValidation("mprovince","req","Please enter your living province");
frmvalidator.addValidation("postcode","req","Please enter your post code");
frmvalidator.addValidation("datein","req","Please tell us when you moved into this place");
frmvalidator.addValidation("primaryphone","req","Please provide your primary contact phone number so that we can reach you fast and easily");
frmvalidator.addValidation("workphone","req","Please enter your work phone number");
frmvalidator.addValidation("cellphone","Please enter your cellphone");
frmvalidator.addValidation("driver","req","Please enter your driver license, if you don't have one, please provide your health card number");
frmvalidator.addValidation("email","req","Please enter your email address and your email address will be your loginID when you come back, Thanks!");
frmvalidator.addValidation("email","email", "The email address is not a correct email format");
frmvalidator.addValidation("cemail","req","Please enter your email address again"); 
frmvalidator.addValidation("cemail","eqelmnt=email","The confirmed email address is not the same as your email");
frmvalidator.addValidation("pwd","req","Please enter your password");
frmvalidator.addValidation("cpwd","req","Please enter your password again");
frmvalidator.addValidation("cpwd","eqelmnt=pwd","The confirmed password is not the same as your password");
frmvalidator.addValidation("r1name","req","Please enter your first reference Name");
frmvalidator.addValidation("r2name","Please enter your second reference Name");
frmvalidator.addValidation("r1phone","req","Please enter your first reference phone number");
frmvalidator.addValidation("r2phone","Please enter your second reference phone number");
frmvalidator.addValidation("r1relation","req","Please tell us your relationship with your first reference");
frmvalidator.addValidation("advertisement","req","Please tell us where did you know www.cash2u.ca? Thanks.");

</script>

<div id="footer">
<div id="imlinks"><b><strong>Copyright &#169 2011 Cash2u.ca All rights reserved</strong></b></div>
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